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Guidelines for chemotherapy of tuberculosis in Taiwan

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Guidelines for chemotherapy of tuberculosis in Taiwan. 馬偕紀念醫院 一般內科及感染科 主治醫師 曾祥洸 2005-3-9. Infectious Disease Society of Taiwan The Society of Tuberculosis, Taiwan Medical Foundation in Memory of Dr. Deh-Lin Cheng (J Microbiol Immunol Infect 2004;37:282-384). - PowerPoint PPT Presentation

Text of Guidelines for chemotherapy of tuberculosis in Taiwan

  • Guidelines for chemotherapy of tuberculosis in Taiwan 2005-3-9

  • Infectious Disease Society of TaiwanThe Society of Tuberculosis, TaiwanMedical Foundation in Memory of Dr. Deh-Lin Cheng (J Microbiol Immunol Infect 2004;37:282-384)Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education CY Lees Research Foundation for Pediatric Infectious Diseases and Vaccines

  • Three principles for the guidelines1. From the viewpoint of primary care physician2. Antimicrobial agents recommended already marketed in Taiwan3. Base on academic principles rather than the regulation of the Bureau of National Health Insurance

  • Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384)New Case

  • Pulmonary tuberculosisDrugs of choice for New case1. Standard regimen: (total 6 months)INH+RIF+EMB+PZA for 2 months,Then INH+RIF+EMB for 4 months2. Fixed-dose combinations: (total 6 months)Rifater+EMB for 2 monthsThen Rifinah+EMB for 4 monthscavitations on initial chest X ray and/or positive cultures at completion of initial 2 months treatment, extend treatment to total 9 months.

  • Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384)Retreatment

  • Pulmonary tuberculosisDrugs of choice for Retreatment (total 8 months)1. Relapse 2. Default 3. Failure INH+RIF+EMB+PZA+IA for 3 months,Then INH+RIF+EMB for 5 months

    IA: Injectable aminoglycosides include streptomycin, kanamycin, and amikacin, and should be administered in the initial 2 months of treatment

  • Retreatment1. Relapse is defined as a patient who develops active tuberculosis (by culture, clinical or radiological deterioration) after completion of anti-tuberculous therapy.2. Default is defined as interruptions in therapy of longer than 2 months.3. Failure is defined as continued or recurrent positive cultures after 4 months of treatment in patients with assured adherence to the prescribed anti-tuberculous regimen.

  • Pulmonary tuberculosisCulture and susceptibility testing should be done immediately and regimen should be tailored to susceptibility testing results. Referral to specialists in Infectious diseases, chest medicine or experts on tuberculosis is recommended.

  • Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384)Drugs Resistance and Drugs Intolerance

  • Drug resistance to INHRIF+EMB+PZA for 6 monthsRIF+EMB+PZA+IA for 6 months

  • Drug intolerance to INHRIF+EMB+PZA for 6 months

  • Drug resistance to RIFINH+EMB+PZA for 9-12 monthsINH+EMB+PZA+IA +/- FQ for 9 months

    Fluroquinolones include ofloxacin, ciprofloxacin and levofloxacin.

  • Drug intolerance to RIFINH+EMB+PZA for 9-12 monthsINH+EMB+PZA+IA +/- FQ for 9 months

    Fluroquinolones include ofloxacin, ciprofloxacin and levofloxacin.

  • Drug resistance to EMBINH+RIF+PZA for 2 months, thenINH+RIFfor 4 months(total 6 months)--

  • Drug intolerance to EMBINH+RIF+PZA for 2 months, thenINH+RIFfor 4 months(total 6 months)

    --

  • Drug resistance to INH, RIF (MDR-TB):EMB+PZA+IA+FQ+TBN () (prothionamide)for 18-24 months*--

    *Treatment duration is a total of 18 months after sputum conversion.

  • Drug resistance to INH, RIF, EMB (MDR-TB):PZA+IA+FQ+TBN () (prothionamide)+PSA ()for 18-24 months*

    --

    *Treatment duration is a total of 18 months after sputum conversion.

  • Drug intolerance to PZAINH+RIF+EMB for 9 months--

  • Drug intolerance to INH, RIF :EMB+PZA+IA+FQ+TBN () (prothionamide)for 18-24 months*--

    *Treatment duration is a total of 18 months after sputum conversion.

  • Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384)3 Special situations

  • Liver function impairment and/or liver cirrhosisRIF+EMB+PZAfor 6 monthsOrINH+RIF+EMBfor 9 monthsRIF+EMB+IA+FQfor 12-18 monthsOrEMB+TBN () (prothionamide) +IA+FQfor 18-24 months

  • Renal function impairment is defined as Ccr
  • Pregnancy or breastfeedingINH+RIF+EMB+PZAfor 2 monthsthenINH+RIF+EMBfor 4 months(total 6 months)INH+RIF+EMBfor 9 months

  • Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384)Dosage of antituberculous agents (for adult only)

  • Dosage of antituberculous agents (for adult only)INH (100 mg)

    RIF (150; 300 mg)

    EMB (400 mg)EMB*

    PZA (250 mg)PZA*5 mg/kg BW qd (maximum 300mg)10 mg/kg BW qd (maximum 600mg)

    15-25 mg/kg BW qd15-25 mg/kg BW qod

    15-30 mg/kg BW qd (maximum 2 g)12-25 mg/kg BW qd

  • Intermittent dosing (3 times weekly) after hemodialysisINH (100mg)

    RIF (150; 300 mg)

    EMB (400 mg)

    PZA (250 mg)900mg

    600mg

    15-25 mg/kg BW

    25-35 mg/kg BW

  • Dosage of antituberculous agents (for adult only)Streptomycin (1g) amikacin (250mg) kanamycin ()

    Ciprofloxacin (250mg)Levofloxacin (100mg)Ofloxacin ()

    15 mg/kg BW qd

    500-750 mg bid 500mg qd400mg bid

  • Dosage of antituberculous agents (for adult only)TBN ()

    PAS ()

    15-20 mg/kg BW, divided to bid-tid (maximum 1 g)

    200 mg/kg BW, divided to bid-qid

  • Dosage of antituberculous agents (for adult only)Rifater (INH 80 +RIF 120 +PZA 250)Rifinah-300 ()(INH 150 +RIF 300 )

    Rifinah-150 ()(INH 100 +RIF 150 )1 tab/10kg BW qd (maximum 5 tab)

    2 tab qd, if BW > 50 kg BW

    3 tab qd, if BW < 50 kg BW

  • Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384)Extrapulmonary tuberculosis

  • Pleurisy, Lymphadenitis, Peritonitis (intestinal disease), Pericarditis, Genito-urinary tract diseaseINH+RIF+EMB+PZAfor 2 monthsthenINH+RIF+EMBfor 4 months(total 6 months)--

  • Bone and joint diseases, pleural empyemaINH+RIF+EMB+PZAfor 2 monthsthenINH+RIF+EMBfor 7 months(total 9 months)--

  • Meningitis, CNS diseaseINH+RIF+EMB+PZAfor 2 monthsthenINH+RIF+EMBfor 10 months (total 12 months)--

  • SteroidsPrednisolone < 1 mg/kg BW qd or equivalent for a minimum of 3 weeksRecommended in PericarditisMeningitisCNS disease

  • Topics not included1. TB - HIV coinfection2. Drug-drug interaction3. Other antituberculosis drugs (rifabutin, cycloserine)4. Treatment of the pediatric population

  • Guidelines for chemotherapy of tuberculosis in Taiwan(J Microbiol Immunol Infect 2004;37:282-384)Thanks for yours attention!